A Few CS Questions

[JGM]

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Hello all.

I've read this forum for a number of months and have found the advice of its members to be quite helpful. I have a couple questions regarding Step 2 CS I'm hoping someone can help with. I read the stickies and other posts in the forum and didn't find the answers, so I apologize in advance if these questions have been answered.

First, is it ever necessary to perform orthostatic vital signs on a patient, for example, one with dizziness or lightheadedness? Most of what I've read says you shouldn't have to perform or repeat vital signs, but it's somewhat ambiguous. If not, do you include it in the workup in the note then? Same with a tilt test in the exam room -- is it necessary to perform this yourself, or should you include it in your diagnostic workup orders in your note?

Second, does anyone know if you get docked points for writing wrong or unnecessary workup tests in your note? Basically, I guess what I'm wondering about is in a circumstance where I have four good workup tests and am looking for a fifth, is it better to just write something that you probably really wouldn't need, or leave it blank? I hope that conveyed what I'm looking for... basically, is there a "no penalty for guessing" policy, if anyone knows.

Thanks in advance for your help.

 

[abbaroodle]

Part of what I find so frustrating about this exam is we are given no feedback and it is so vague that I have no idea what is expected and what is considered complete and thorough. Since I have no idea how the test is graded, its hard to answer those questions!!!

I did not do orthostatics or a tilt-test on anyone. I had one that maybe I should have done both. But in 15 mins, you just dont have time to ask and do everything you would in real life. So if you have time and think orthostatics or the tilt-test are warranted, do them. If you dont have time or dont do them, don't loose sleep over it.

Given that the note is graded in part on the "absence of harmful actions to the pt" I would say if a test is high risk and totally unnecessary, it might hurt you. (Like doing a cardiac cath for a pt with an ankle injury.) But I was wondering the same thing when I took the test. I tended towards the more is better side of things. But I have no idea if this helped or hurt me.

For H&P, no points docked for asking unnecessary q's or performing extra maneuvers, so ask away.

 

[rox]

I wouldn't do any test that takes substantial period of time. I'd just ignore it or include it with the investigation.

I would choose not to include irrelevant investigation, but in most cases one can't run out of relevant investigations to include.

Remember, you don't need to include everything.

 

[JGM]

Thank you both very much for your replies. That's helpful information, and more or less in line with what I was thinking. Like many preparing for this exam, though, I like to hear the thoughts of others.

Appreciated again. Good luck to any other CS takers out there.

 

[zola]

I just took CS this week - they actually specifically mentioned the orthostatic vital signs in the little video intro we had to watch - it said you are welcome to do them, but you should not consider the results when formulating your plan for treatment. They kept emphasizing that you should use the vitals they give you and accept them as accurate. So, I would say definitely do NOT do orthostatic vital signs, even if you would in real life. You only have 15 minutes, and although there were a handful of cases that I finished early, these were not the ones where the patient was complex enough to warrant orthostatics.

Re the penalty for guessing - I really don't know. It seems really subjective - some random MD is going to read your note and decide if your clinical reasoning makes sense. So if the test you're considering is really random, probably better not to include it because that wouldn't reflect good clinical reasoning. But if it is related to even the most far-out possibility on your differential list, then why not.

 

[JGM]

Great information, thanks zola. I looked through the still frames of the orientation video posted on the USMLE website, and I either missed that specific bit of info, or it didn't make it to the still frames. Good to know.

And yeah... about the workup tests -- I certainly would leave it blank before putting something way-out-there-random. I've been going through First Aid and some other cases, have gotten stuck a few times looking for a fifth test, and have thought, "Well I already wrote abdominal x-ray, maybe a CT abdomen too?" or, "I suppose a CBC wouldn't hurt." It seems like the consensus is if it's dealing with the problem at least in some way, might as well.

Thanks again for your reply.

 

[Law2Doc]

I just took CS this week - they actually specifically mentioned the orthostatic vital signs in the little video intro we had to watch - it said you are welcome to do them, but you should not consider the results when formulating your plan for treatment. They kept emphasizing that you should use the vitals they give you and accept them as accurate. So, I would say definitely do NOT do orthostatic vital signs, even if you would in real life. You only have 15 minutes, and although there were a handful of cases that I finished early, these were not the ones where the patient was complex enough to warrant orthostatics. ...

Yeah, to check orthostatics properly, you are really supposed to wait 2 minutes between changes of position. So if you checked patient lying, seated and standing (what you'd probably do in a hospital setting) with a 2 minute wait between each, that's all your time.